RE-DUAL PCI randomized evaluation of dual antithrombotic therapy with dabigatran versus triple therapy with warfarin in patients with nonvalvular atrial fibrillation undergoing percutaneous coronary intervention. SENIOR Short-term dual antiplatelet therapy with the SyNergy II stent in patients older than 75 years undergoing percutaneous coronary intervention.
Preamble
Introduction
Definitions | Acute coronary syndrome and myocardial
Epidemiology of acute coronary syndromes
Triage and diagnosis
- Clinical presentation and physical examination
- Clinical presentation
- Physical examination
- Diagnostic tools | Electrocardiogram
- Acute coronary syndrome with persistent ST-segment
- Acute coronary syndrome without persistent ST-
- Diagnostic tools | Biomarkers
- High-sensitivity cardiac troponin
- Rapid ‘rule-in’ and ‘rule-out’ algorithms
- Other biomarkers
- Diagnostic tools | Non-invasive imaging
- Cardiac magnetic resonance imaging with or without
- Single-photon emission computerized tomography
- Differential diagnosis for acute chest pain
Acute coronary syndrome with persistent ST-segment elevation or other signs of acute ST-segment elevation of the vessel or other signs of acute vessel occlusion. This figure highlights some of the electrocardiographic abnormalities that may be present in patients with NSTE-ACS.
Initial measures for patients presenting with suspected acute
Pre-hospital logistics of care
- Organization of ST-elevation myocardial infarction
The majority of patients presenting to the emergency department with acute chest pain have noncardiac conditions that cause chest discomfort. Characteristics of chest pain can help in its early identification to some extent.
Acute-phase management of patients with acute coronary
Acute coronary syndrome managed with invasive strategy
Patients not undergoing reperfusion
- Patients who are not candidates for invasive coronary
- Patients with coronary artery disease not amenable to
Antithrombotic therapy
Long-term treatment
- Prolonging antithrombotic therapy beyond 12 months
Add a second antithrombotic agent to aspirin for extended long-term secondary prevention in patients at high ischemic risk and without HBR. Drugs (in addition to aspirin 75–100 mg/d) for extended DAPT treatment options are in alphabetical order.
Antiplatelet therapy in patients requiring oral anticoagulation 17
- Comparison of fibrinolytic agents
- Hazards of fibrinolysis and contraindications
The primary endpoint of clinically significant bleeding events was significantly lower in the two groups receiving rivaroxaban than in the group receiving standard therapy. All-cause death or hospitalization was significantly reduced at 1 year in the two groups that received rivaroxaban compared with the group that received standard therapy. The incidence of the composite efficacy endpoint was 13.7% in the two DAT groups combined compared with 13.4% in the TAT group.
Patients in the aspirin group had a similar incidence of death or hospitalization and of death or ischemic events compared with the placebo group.
Antithrombotic therapy in patients not undergoing
In the STREAM (Strategic Reperfusion Early After Myocardial Infarction) trial, baseline excess intracranial hemorrhage in patients 75 years of age and older was reduced after a protocol change to reduce the tenecteplase dose by 50%. The risk of moderate to heavy bleeding appears to be greater in women than in men. Re-administration of streptokinase should be avoided, both because antibodies may impair its activity and because of the risk of allergic reactions.
In patients with refractory cardiac arrest, lytic therapy is not effective, increases the risk of bleeding, and is not recommended.
Acute coronary syndrome with unstable presentation
Out-of-hospital cardiac arrest in acute coronary syndrome
- Healthcare systems and systems of care
Fibrinolysis Hazards and Contraindications Fibrinolytic therapy is associated with a small but significant excess Fibrinolytic therapy is associated with a small but significant excess of strokes largely attributable to cerebral hemorrhage, with the excess risk occurring on the first day after treatment.156 High age, lower weight, female gender, previous cerebrovascular disease, black population, previous stroke, and systolic and diastolic hypertension on admission are significant predictors of intracranial hemorrhage.157 High age is also associated with rupture of the free LV wall. Data from several studies indicate that major non-cerebral bleeding occurred in 4-13% of treated patients. The most common site of spontaneous bleeding is the gastrointestinal tract. Administration of streptokinase may be associated with hypotension, but severe allergic reactions are rare.
Prolonged/traumatic but successful resuscitation increases the risk of bleeding and is a relative contraindication for fibrinolysis.160.
Management of acute coronary syndrome during hospitalization
Coronary care unit/intensive cardiac care unit
A fibrin-specific agent is preferred.154 A single bolus of weight-adjusted tenecteplase tissue plasminogen activator (tPA) is equivalent to accelerated tPA in reducing 30-day mortality, but is safer in preventing non-cerebral hemorrhage and blood transfusions . in addition to being easier to use in the pre-hospital setting.155.
In-hospital care
- Duration of hospital stay
- Risk assessment
- Clinical risk assessment
- Biomarkers for risk assessment
- Bleeding risk assessment
- Integrating ischaemic and bleeding risks
- Evaluation of long-term risk before discharge
Given that the GRACE risk score predicts clinical outcomes, it allows patients to be stratified according to their estimated risk of future ischemic events. The GRACE risk score was originally developed to estimate the risk of in-hospital death.127 Essentially, all GRACE risk score models calculated at hospital presentation use the same eight variables (four continuous variables: age, SBP, heart rate). level and serum creatinine; three binary variables: cardiac arrest on admission, elevated cardiac biomarkers, and ST segment deviation; and one categorical variable: Killip class at presentation) to predict risk. Covariates should be entered into the GRACE risk assessment calculators (i.e., printable charts, online calculators, and mobile phone apps) as a range, not as exact numerical values.
However, assessment of these markers has not been shown to improve patient management and add value to risk assessment in addition to GRACE and/or BNP/ risk calculation.
Technical aspects of invasive strategies
Percutaneous coronary intervention
- Intravascular imaging/physiology of the infarct-related
- Intravascular imaging
- Intravascular physiology
- Embolic protection and microvascular salvage strategies
- Interventions to protect the microcirculation
DAPT score ≥25), prolonged DAPT was associated with no ischemic benefit but an increased risk of bleeding events. 222 In contrast, longer treatment in patients without HBR (ie, PRECISE. However, for most patients in the study, DAPT consisted of aspirin and clopidogrel. OCT guidance led to post-PCI optimization in 29% of cases (59% for dissection and 41% for dissections); at 9 months, OCT analysis showed significantly lower area-to-segment stenosis in the OCT-guided group, with no difference in MACE.230.
Early administration of the beta-blocker metoprolol has been shown to reduce the presence and extent of MVO in patients with anterior STEMI in the METOCARD-CNIC (Effect of METOProlol in CARDioproteCtion during an acute myocardial infarction) trial.254 In this small trial. (n = 270), early i.v.
Ongoing major trials
Management of patients with multivessel disease
Myocardial infarction with non-obstructive coronary arteries
- Characteristics, prognosis, and symptoms at presentation
- Invasive coronary angiography
- Functional coronary angiography
- Intravascular imaging (intravascular ultrasound/optical
- Left ventricular angiography, pressure, and function
- Non-invasive evaluation
- Management of myocardial infarction with non-obstructive
May be constant or intermittent, or intensity waxes and wanes Sometimes radiates to left arm, neck, or jaw. Women, elderly patients and patients with diabetes are more likely to present with less common symptoms. Less common presentations of symptoms are seen more often in elderly patients, in women, and in patients with diabetes, chronic kidney disease, or dementia.
MINOCA, myocardial infarction with non-obstructive coronary arteries; NSTEMI, non-ST elevation myocardial infarction; STEMI, ST elevation myocardial infarction.
Special situations
Complications
- Heart failure
- Mechanical complications
- Post-acute coronary syndrome pericarditis
- Bleeding
- Management of bleeding
- Bleeding events on non-vitamin K antagonist oral
- Bleeding events related to percutaneous coronary
- Bleeding events related to coronary artery bypass
- Transfusion therapy
The use of antithrombotics and/or anticoagulants (in the presence of LV thrombus, AF, or other indications) in patients with post-infarction pericarditis with or without pericardial effusion appears to be safe.291. With patients treated with Factor Xa (FXa) inhibitors (apixaban, edox-aban, rivaroxaban), prothrombin complex concentrate should be the first-line treatment.299 A specific antidote for FXa inhibitors, andexanet alfa, has been tested in patients with major acute. bleeding associated with FXa inhibitors. Recombinant factor VIIa should only be used for rescue therapy in patients with uncontrollable bleeding events in whom other correctable causes (eg, hypothermia, coagulation factor deficiency, fibrinogen deficiency) have been managed because of concerns about association with an increased risk of graft thrombosis.312.
However, the accumulated evidence for these compounds in patients with congestive HF strongly suggested that they have no beneficial effect on mortality and may be harmful due to an increased risk of thromboembolism and hypertension.316.
Comorbid conditions
- Patients at high bleeding risk and with blood disorders
- Thrombocytopenia following GP IIb/IIIa inhibitor
- Heparin-induced thrombocytopenia
- Chronic kidney disease
- Older adults with frailty and multimorbidity
- The older person
- Frailty and multimorbidity
- Pharmacotherapy in older and frail patients
- Pregnancy
- Drug abuse
- Acute coronary syndrome associated with alcohol
- Acute coronary syndrome associated with illicit
- Patients with cancer
- Pathophysiology
- Clinical presentation
- Initial management and acute multidisciplinary
- Invasive strategy
- Antithrombotic treatment
- Thrombocytopenia and cancer
- Cancer treatment
- Coronavirus disease (COVID-19)
The number and severity of comorbidities are inversely related to the rate of coronary angiography and PCI in patients with ACS. Furthermore, current cancer is more often associated with a more conservative management strategy than that used in patients with no cancer or history of cancer.368,373. Patients with a history of cancer should be treated in the same way as all other ACS patients.
Cardiovascular comorbidities are common in patients with coronavirus disease 2019 (COVID-19), and the presence of cardiovascular disease is associated with severe COVID-19 and higher mortality.
Long-term treatment
Lifestyle management
- Nutrition and alcohol
- Resumption of activities
- Sexual activity
- Environmental factors
The same ECG diagnostic criteria for cardiac conditions apply to patients with SARS-CoV-2 infection and to the general population. In patients hospitalized with COVID-19, mild increases in cTn are generally due to pre-existing cardiac disease and/or acute injury. SARS-CoV-2 infection is associated with an increased thrombotic burden.381,382 However, COVID-19 does not change the management (including organized networks) of patients with ACS.383 The PPCI strategy remains the treatment of choice for patients with STEMI. 384 Fibrinolysis is indicated (always within the first 12 hours of myocardial infarction) only in those who are not expected to undergo PCI-mediated reperfusion within 120 minutes of STEMI diagnosis.
Reports have highlighted the unfavorable prognosis of ACS patients with comorbidities of COVID-19.385,386 Therefore, appropriate vaccination against COVID-19 is recommended for patients with ACS.
Pharmacological treatment
- Lipid-lowering therapy
- Hormone replacement therapy
A recent study examining initiation of PCSK9 inhibitor therapy in the acute phase of ACS showed that evolocumab added to high-intensity statin therapy was well tolerated and resulted in an early substantial reduction in LDL-C values, with >95% of patients achieving the currently recommended LDL level. -C goals within 4–8 weeks.414 Initiation of treatment with a PCSK9 inhibitor is recommended in patients with ACS who do not achieve their LDL-C goal after 4–6 weeks of maximum tolerated treatment with statins and ezetimibe. In patients presenting with ACS whose LDL-C levels are not at target despite already taking a maximally tolerated dose of statin and ezetimibe before the event, the addition of a PCSK9 inhibitor shortly after event (during hospitalization for the ACS event if possible) should be considered. Therefore, ico-sapent ethyl, at a dose of 2 g twice daily, can be considered in combination with a statin in patients with ACS and triglyceride levels of 1.5–.
There are no results yet; a large CV outcomes trial is currently comparing inclisiran versus placebo in patients with previous MI or stroke.
Patient perspectives
- Patient-centred care
- Informed consent
- Research participation and consent in the acute setting
- Patient-reported outcome measures and patient-reported
- Preparation for discharge
The use of a brief oral informed consent procedure followed by supplementary written information after the acute phase seems appropriate from the patient's perspective. They measure the patient's perception of quality of life, disease status and general health. Therefore, patient-centered care is important because it recognizes and incorporates the patient's values and wishes in providing the necessary medical care.
Before discharge, all aspects of self-care should be reviewed with the patient to improve patient understanding.
Gaps in evidence
